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Medicare Stars & Risk Practice Consultant

Company: Wellmark Blue Cross and Blue Shield
Location: Cedar Rapids
Posted on: January 15, 2022

Job Description:

Job Summary

Help us launch one of the fastest-growing lines of business in the nationWellmark Blue Cross and Blue Shield is on a mission to provide quality and affordable health insurance to more Iowans and South Dakotans than ever before. That's why we're launching a new line of business in the Medicare Advantage market. Now is your chance to be a part of something bigger.Use your strengths as Medicare Stars & Risk Practice ConsultantIn this newly created role, you will provide day-to-day management and oversight for: Wellmark's Medicare Stars, quality and clinical risk initiatives and strategies focused on design and implementation of Stars initiatives and risk adjustment related activities. You'll partner with internal stakeholders in analyzing, measuring, and improving the Medicare Star ratings, quality metrics, member satisfaction, level of services received, and related risk adjustment and quality improvement projects and initiatives. You'll lead provider performance improvement strategies in Star measures, quality improvement and risk adjustment related activities across Iowa and South Dakota. In addition, you'll leverage experience in strategy development, analytics, data insight development, process management, program management, and organizational change management to drive results with regard to Medicare, Medicare Advantage and Medicare Star Ratings, quality and risk adjustment.Our strongest candidates enjoy analyzing data, working with teams to creatively solve problems, and they're skilled at influencing direction/action. They also love collaborating with others to drive progress and continuous improvements.


Required:Bachelor's degree or direct and applicable work experience.3+ years of related healthcare industry experience that reflects analysis of health care quality related data and network management or provider relations.Demonstrates the ability to think strategically to ensure program success.Excellent analytical skills, data management capabilities, and strong attention to detail. Technical aptitude to learn new data -management and analysis tools or methodologies quickly.Effective consultation and critical thinking skills. Ability to review data and provide measurable outcomes and trend measures to support and influence business decisions.Strong written and verbal communications skills with the ability to share technical insights and recommendations with varying -stakeholder audiences, including healthcare providers and external vendors. Adapts communication based on audience.Self-starter able to produce quality results based off sound decision making skills. Effective time management with -flexibility and adaptability to change.Collaborative approach to work with and ability to partner with different business areas.Proficiency with the Microsoft Office Suite.Ability to travel multi-state (IA / SD) up to 50%, as needed.Preferred:Nursing degree or master's degree in related field.Coding certification or demonstrated level of knowledge, skill and understanding of industry standard ICD-10-CM and CPT coding principles.Knowledge base of CMS Star measures, clinical standards of care, preventive health, and risk adjustment.Knowledge of CMS rules and requirements of Medicare Advantage health plans.Knowledge of billing or claims submission and other related actions.Ability to deliver training materials designed to improve provider performance.Comfort building relationships with clinical and non-clinical personnel.


a. Provide day-to-day management and oversight for Wellmark's Medicare Stars and clinical risk adjustment initiatives. Manage end-to-end processes across all Stars measures while collaborating with and engaging leaders to define, shape and drive the Stars and quality improvement strategies. Leads in the data management and reporting of measures to internal and external audiences as appropriate, coordinating audits, and presenting results in reports and/or dashboards that are easily consumable.b. Partner with internal stakeholders and/or external vendors in the definition, design, implementation, and maintenance of data files and data extracts to meet quality reporting needs of Wellmark's Medicare Stars and clinical risk initiatives. Adhere to established data governance standards, CMS Star Rating technical specifications and risk adjustment coding specificity requirements. Accountable for the integrity of the data.c. Lead the development and maintenance of provider incentives, and integrated, comprehensive, and actionable reporting. Provide consultative and analytical expertise to internal and external stakeholders, including Wellmark leadership, Wellmark providers and vendors.d. Monitor and leverage best practices from other 45star plans to continuously improve Stars performance. Share best practices to improve provider processes and workflows for optimal Star ratings across the Medicare Advantage business. Draw conclusions and make recommendations to leadership that will help achieve overall Star measures and quality goals.e. Analyze data - i.e., Star measure performance, gaps in care, clinical, satisfaction, health outcomes, utilization, risk adjustment & other as indicated to evaluate performance, identify and prioritize provider outreach strategies for Stars measure improvement, risk adjustment initiatives and Medicare advantage quality projects, with the goal to maximize member and provider experience, quality, and Star measure outcomes determine and communicate/escalate organizational risk or impact of performance gaps or noncompliance.f. Ability to independently travel across Iowa and South Dakota to meet with providers to review Wellmark data, tools and incentive programs for Stars measures, quality reporting and risk adjustment to improve the quality of care for Medicare Advantage Members.g. Establish positive, long-term, consultative relationships with providers, including independent physicians, physician groups, health systems and ACOs.h. Develop comprehensive, provider-specific plans to increase their Stars and quality performance, facilitate risk adjustment coding specificity opportunity reviews and improve practice outcomes.i. Partner with providers to engage in Wellmark member programs, provider incentives and vendor engagement.j. Coordinate and provide ongoing strategic recommendations, training, and coaching to providers on program implementation, opportunities, and resolution.k. Lead regular Stars, quality, and risk adjustment specific provider meetings to drive action plans, continual process improvement and achievement of performance goals.l. Facilitate / lead monthly and/or quarterly meetings with health plan leadership, including material preparation and report outs.m. Provide reporting to health plan leadership on progress of overall Stars measure and risk adjustment performance, including Medicare Advantage Physician incentives, provider risk arrangements, vendor performance, and trending of health plan performance against established goals.n. Other duties as assigned.Job SummaryJob ID: 214924Category: Medicare AdvantageRequires Non-Compete?: Yes

Keywords: Wellmark Blue Cross and Blue Shield, Cedar Rapids , Medicare Stars & Risk Practice Consultant, Other , Cedar Rapids, Iowa

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